Exhibit T_Fermilab Subcontractor Safety Information Questionnaire.pdf
PDF 113 KB Posted
- Solicitation number
- 372698_DG
About this file
This document is a Fermilab Subcontractor Injury & Illness Data Questionnaire designed to collect comprehensive safety performance information from potential subcontractors. The form requires companies to provide detailed workplace injury and illness data, including the interstate experience modification rate for the past three consecutive years, workers' compensation carrier details, and OSHA 300 log information. Subcontractors must calculate and report total recordable case rates and days away, restricted, or job transferred case rates averaged over three years, along with providing the name and contact information of the individual responsible for safety.
The questionnaire includes formulas for calculating various safety metrics, such as Total Recordable Case Rate (TRCR) and Days Away, Restricted or Transferred Case Rate (DARTR), which are computed using the number of recordable cases, employee hours worked, and a standard multiplier of 200,000. Companies must attach supporting documentation like NCCI Workers Compensation Experience Rating forms and OSHA 300A Form log summaries for the three years under review. The form concludes with a certification section where the information provider must sign and attest to the accuracy of the submitted data.
View the file
Other files
Show all 29
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Fermilab ES&H Manual 7010-F1-1 WARNING: This manual is subject to change. The current version is maintained on the ESH&Q Section website. Rev.07/2018
Fermilab Subcontractor Injury & Illness Data Questionnaire
Date ____________ Company Name _______________________________________________ NAICS (6 digits)1 _______________________________________________
Address _______________________________________________ Phone Number _______________________________________________ Owner _______________________________________________
1. List interstate experience modification rate for the past three consecutive years.
(Provide a copy of the NCCI Workers Compensation Experience Rating form for each of the years being considered)
Current Year _______ Previous Year _______ 2 Years Previous _______
2. Name of the Workers’ Compensation Carrier __________________________
Policy Number ________________________________________________ Address ________________________________________________ Phone Number ________________________________________________
Name of Contact for Ins. Info _______________________________________
3. Using the OSHA 300 log, fill in the number of injuries and illnesses for the past three years (attach copies of the OSHA 300A Form log summary for the three years being considered).
Description Current Year
Previous Year
2 Years Previous
A Total Number of Recordable Cases (RC)
B Total Recordable Case Rate (TRCR)
C Total Number of Cases with Days Away, Restricted or Job Transferred (DART)
D Days Away, Restricted or Job Transferred Case Rate (DARTR)
E Employee Hours Worked (EHW)
F Number of Fatalities
Fermilab ES&H Manual 7010-F1-2 WARNING: This manual is subject to change. The current version is maintained on the ESH&Q Section website. Rev.07/2018
4. Calculate the total recordable case rate averaged over three years _________
5. Calculate days away, restricted or transferred case rate average over three years _________
6. List name and phone number of individual in company responsible for safety
Name _____________________ Phone Number_________________ Years of Service ____________ Safety Training/Qualifications/Certifications ___________________________
I certify that the information provided on this document is true.
Signature Information supplied by:
Printed Name
Instructions
1) It is strongly recommended that the person completing this form is the person responsible for Safety.
He/she should be familiar with the information requested.
Formulas
EHW
xRCTRCR )000,200()(
= DARTR=
EHW
xDART )000,200()(
Previous
Item 4: Recordable Case Rate Average =
𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇(𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶 𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌) + 𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇(𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌) + 𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇(2 𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑖𝑖𝑖𝑖𝑢𝑢𝑠𝑠)
Item 5: Lost Work Day Case Rate Average =
𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷(𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶 𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌) + 𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷(𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌) + 𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷(2 𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃)
Note 1: NAICS- North American Industry Classification System, formerly known as SIC or Standard Industry Classification Code (Please enter all six digits)
Instructions
File details come from the government source that posted it. Updated .